Department of Policy, Records, and Reporting
MONTGOMERY COUNTY PUBLIC SCHOOLS
Rockville, Maryland 20850
NEW STUDENT INFORMATION
INSTRUCTIONS: This form is to be completed by parent or legal guardian. For all students new to or reentering MCPS,
the verification of the following must be presented at the time of enrollment: Montgomery County residency, age and immunizations, unless homeless.
Must match birth certificate or other evidence of birth
Legal Last Name
Legal First Name
Legal Middle Name
School Name
□ Male □ Female Grade ID #
Social Security Number
Date of Birth
Language Spoken at Home
Proof of Age
□ Birth Certificate/Registration □ Baptism/Church Certificate □ Hospital Certificate □ Passport/Visa □ Parent’s Affidavit
□ Physician’s Certificate
□ Other
Residency
Street Address
City
State
Zip
Home Phone
E-mail Address
Circumstance (if applicable)
□ Homeless (complete MCPS Form 335-77, Homeless Status)
□ Informal Kinship Care (complete MCPS Form 334-16, Informal Kinship Care Status and MCPS Form 334-17, Affidavit:
Children in Informal Kinship Care)
□ Maryland State Supervised Care (complete MCPS Form 560-35, Enrollment of Child in Maryland State-Supervised Care and
Transfer of Educational Records)
Proof of Residency—MCPS Regulation JEA-RB, Enrollment of Students, requires a copy of one of the following unless homeless:
□ Current property tax bill
□ Current lease
□ If lease is more than 1 year old, lease and current utility bill
□ Shared Housing Disclosure Form (MCPS Form 335-74)
□ Determination of Residency and Tuition Status Form (MCPS Form 335-73)
Language for Written Communication
□ Chinese
□ English □ French
F-1/J-1 Immigration Status □ Yes If No: Date entered U.S.
□ Korean □ Spanish
□ N/A
□ Vietnamese
U.S. Citizen □ Yes □ No
Date of 1 entry into U.S. school
st
Immunizations
Proof of immunization compliance—MCPS Regulation JEA-RB: Enrollment of Students, requires a copy of one of the following:
□ Maryland Department of Health and Mental Hygiene Immunization Certificate 896
□ Computer-generated printout from doctor’s office
□ Other
Ethnicity
1. ETHNICITY DESIGNATION. Read the definition below and check the box that indicates this student's heritage.
Is this student Hispanic or Latino? (Select one answer.)
Persons of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race,
are considered Hispanic or Latino. □ Yes □ No
2. RACE DESIGNATION. Read the descriptions below and check the boxes that indicate this student's race. You must select
at least one race, regardless of ethnicity designation. More than one response can be selected.
Indicate this student’s race. (Select all that apply.)
American Indian or Alaskan Native: A person having origins in any of the original peoples of North or South America
□ (including Central America), and who maintains a tribal affiliation or community attachment.
Asian: A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent
□ including Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, or Vietnam.
B
□ lack or African American: A person having origins in any of the black racial groups of Africa.
Native Hawaiian or Other Pacific Islander: A person having origins in any of the original peoples of Hawaii, Guam,
□ Samoa, or other Pacific Islands.
White: A person having origins in any of the original peoples of Europe, the Middle East, or North Africa
□ MCPS Form 560-24, May 2013
Prior School Experience
Has student previously attended a Montgomery County Public School? □ Yes □ No
If yes
Name of last Montgomery County Public School attended
Dates of attendance
Last Grade
NAME AND ADDRESS OF LAST SCHOOL ATTENDED
__________________________________________________________________________________ ___/___/___ _______
Date of withdrawal Last Grade
□ Public School □ Private School
Name of adult responsible for student living at current address:
Name of adult responsible for student living at current address:
Relationship: □ Parent Relationship: □ Parent □ Guardian
□ Guardian
□ Other
□ Other
Employer
Employer
Work Phone
Work Phone
Cell Phone
Cell Phone
Name of parent/guardian (if other than responsible adult above):
Name of parent/guardian (if other than responsible adult above):
Relationship: □ Parent Relationship: □ Parent □ Guardian
□ Guardian
□ Other □ Other Address:
Address:
Phone
Phone
Sibling's (name)
Birth date
Current School
Non-custodial parent (if applicable)
NameAddress
Custody concerns? □ Yes □ No If yes, contact school.
OTHER INFORMATION
Does the student have an IEP?
□ Yes □ No
Does the student have a 504 plan?
□ Yes □ No
Has the student been in an ESOL program?
□ Yes □ No
Has the student ever been suspended from school?
□ Yes □ No
If yes, is the student currently suspended?
□ Yes □ No
Has the student ever been expelled from school?
□ Yes □ No
If yes, is the student currently expelled from school?
□ Yes □ No
If enrolling after start of school year, do you want directory information to be withheld?
□ Yes □ No
If yes, please request form from school staff.
□ Yes □ No
The information as submitted on this form and on any attachments is accurate, complete and true to the best of my knowledge.
I understand that falsification of any information submitted shall be cause for denial of enrollment. Furthermore, I understand I
am responsible for reporting to the school principal if the student becomes a non-resident of this county and that I am liable for
tuition for any periods that the student may be a non-resident, unless homeless. If my child has an IEP, I understand that an IEP
team must determine his/her placement.
Signature, Parent/Legal Guardian
Date